How does Canadian health care compare?

A recent report describes how Canada’s healthcare system performs compared to 13 other countries.

Canada ranked at the bottom in access to care and use of electronic health records, and in the middle regarding costs and health outcomes.

Thirty-eight percent of Canadians felt the system works well, 51% thought it needs fundamental change, and 10% believed it needs to be completely rebuilt.

A recent report from the American organization The Commonwealth Fund provides information about how Canada’s health care system compares to those in thirteen different high-income countries. Some of the findings are summarized here.

Access to Care

Canada consistently ranked poorly on access to care. In Canada, wait times were longer than in any of the other country for specialist appointments and elective surgeries. For example, 41% of Canadians waited two months or more to see a specialist, compared to just 5% of Swiss and 7% of Germans. One in four Canadians waited four months or more for elective surgery, compared to none in Germany and 5% in the Netherlands.

Canada was the second worst country for accessing health care after hours. Sixty-five percent of Canadians report that it is very or somewhat difficult to find care after regular business hours, compared to 33% of people in the Netherlands.

This poor performance has occurred even after the federal government commited $4.5 billion to reduce wait times in 2004, as well as major investments by the provinces. Stephen Duckett, an Australian health economist and former CEO of Alberta Health Services says that “the waiting list money was highly targeted at specific services, such as hip replacements” and that other countries like the United Kingdom have been able to reduce wait times by setting up aggressive targets for providers and penalties if the targets were not met. At the same time, funding for health care was markedly increased in the UK.

Electronic Medical Records

While significant investments have been made to increase the number of primary care providers, Canadian primary care doctors had the lowest use of electronic medical records in their practices – 37% in Canada, 46% in the United States, and above 90% in seven countries.

The poor uptake of electronic medical records in primary care has occurred despite considerable investments in eHealth provincially and nationally. Tom Noseworthy, a Professor of Community Health Sciences at University of Calgary argues that there was “an insufficient investment in [electronic medical records] Canada-wide that did not operate from a careful blue print on how to achieve gains in every province” leading to a situation where “there are little pockets of doctors using electronic medical records that do not connect as a whole”.

Duckett believes that “the introduction of electronic health records is much more complicated in primary care because of the disorganized nature of primary care, as opposed to the hospital sector.

Hospitals

The report also includes measures related to hospitals. Canada had the fewest acute care beds per population and the highest average length of stay (7.7 days). This information suggests that few Canadians are being admitted to hospitals unnecessarily, which is a good thing. However, the lack of hospital beds for acutely ill patients is a major cause of emergency department overcrowding, and our long wait times for some surgical procedures suggest that more hospital beds are needed to accommodate these procedures.

However, this may not require the construction of more hospital beds, because about 14% of hospital days in Canada are currently taken up by patients who no longer need acute care. Investments in community and long-term care might help the hospital sector. Noseworthy believes that “it is a good thing that Canada has been able to get by with so few acute care beds” and that in spite of the low numbers of beds, they are still “not being used optimally.” He suggests that “we do not have good substitutive services, leaving acute care beds as the only port in the storm for sick patients who could receive care in less acute, sub-acute or intensive home care environments.”

Costs of Health Care

All countries in the report had some form of publicly funded health care paid by government revenues from taxes. However, the amount spent on health care varied markedly. Canada was in the middle of the pack when it comes to the percentage of gross domestic product (GDP) spent on health care. The United States spent by far the most at 17.4%, and Japan spent the least at 8.5%. Canada was similar to countries like Denmark, France, Germany and Switzerland, and spent 11.4% of annual GDP on health care in 2009.

Canada’s proximity to the United States means that we often compare our health care system with our neighbour to the south. However, as mentioned above, the United States spent by far the most on health care of any country, and its measures of quality were frequently among the worst and rarely among the best (except for access to specialists and surgeries). We might gain valuable insghts by carefully looking at the health care systems of other countries.

Public Satisfaction with Health Care

While performing poorly in terms of access to care and the use of electronic health records, Canada was average in survival after a heart attack and was in the top two performing countries in survival after the diagnosis of breast cancer and the frequency of a lower-limb amputation in persons with diabetes. Given this mixed picture in performance, it is not surprising that Canadians were far from unanimous in their views about the need for change in the health care system – 38% felt the system worked well with only minor changes needed; 51% felt that fundamental changes were needed, and 10% felt that the health care system needed to be totally rebuilt.

These numbers are similar to most of the other countries. The greatest desire for change was expressed by citizens in Australia and the United States, with 20 and 27% respectively saying that their health care system needed to be totally rebuilt. The United Kingdom was on the other extreme, with 62% of citizens feeling that the system worked well, and only 3% indicating that the system needed to be totally rebuilt.

Do you think that the Commonwealth Report paints a fair picture of Canada’s health care system?

Yes

No

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Featured reader comments

July 27 2014, 8:17 PM

… In one instance, I faced a 6 month wait for prolapse surgery on top of the 4 month wait to see the specialist, making 10 months in total. Time from GP referral to treatment is therefore routinely extensive.

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18 Comments

RItika Goel

February 9, 2012 at 9:03 PM

Thank you for this very valuable piece! I often feel that we can get very internally focused and need to step back and get more perspective from other countries. One of the major differences between Canada and other OECD countries that isn’t mentioned here though is our public-private spending split. We do spend about the middle-of-the-pack in general, but our funding is also only 70% public and 30% private (spending on drugs, dental, rehab, vision etc). Most European nations have closer to an 80-20 split and with doing this, offer many more services, often including drugs, dental, sometimes homecare etc. The maximal efficiency of having a single payer system is important – our administration costs in OHIP are somewhere between 1-2%, whereas they are more than 10% in the private funding sectors of our healthcare system due to multiple insurance companies etc (similar issues as with the US healthcare system). Especially in a day and age where the antiquated definition of ‘medically necessary services’ falls far beyond simply doctor and hospital services – we can’t even imagine ‘medicine’ without ‘medicines’ for outpatient chronic disease management. We should be looking to see how we can save money as a country by taking more services under the Canada Health Act, saving us money overall with the simplicity of the single payer system. Many European countries spend the same amount (or less) than Canada but offer much more in their universal health care system than we do currently, and it doesn’t have to be this way!

When it comes to electronic medical files I have told my Doctor in no uncertain terms if he puts my file in any computer that has Internet access I will sue him into oblivion. I care not one bit if the government want my med file online, I don’t and will do all in my power to keep them PRIVATE!

As for the rest of it, I am sick and tired of having to pay for others healthcare. Allow people the choice to opt out of the communist government control of the healthcare business. I just want to pay cash when I see my Doctor.

I’m not really sure what you mean by wanting your records to stay private. Whether medical records are on paper or are electronic, they are all protected by confidentiality. Health care professionals cannot share this information without due cause Eg. your permission, collaborating with other health workers to treat you or a transfer of your file if you change family doctors.

This is a very imbalanced report presenting Canada in a negative light, and fails to present areas where Canada ranks high. For example, Canada ranks in the top 9th of 31 OECD countries of overall health care provision. Since the report focuses on ranking of OECD countries, we need to see all the rankings of major areas, including positive aspects of Canadian Health Care, to provide a contextual report. Furthermore, the map of the world in the masthead deceives readers in believing that this is an OECD report. The question on the top “Do you think that the Commonwealth Report paints a fair picture of Canada’s health care system?” is also misleading and misrepresents OECD as this piece does not in any way represent the OECD reports due to lack of balance and author biases.

This is a good summary. I particularly liked the overview of Countries compared. It is fairer than most comparisons I have seen. I do want to understand why “wait times” were lumped together. I also want to understand overall why specialty surgical wait times across the country took 20 years to develop measurement criteria and eventually only produced weak results on “report cards” when other measures could, and are now more sensitive to actual effectiveness to real system change at the hospital departments and in the community setting.
There was also not much revelation of the definition of how we can measure the entire cost of health care in relation to overall national productivity ratios rather than just GDP (a growth only ratio).
The glaring gap in our lack of not coming to consensus in data equity even now is a pillar vs collaborative turf war issue and a micro vs. macro definition issue (1st normal form solutions) and is easily resolved if interdisciplinary functional groups can actually work together and use some open source functions and software development across the nation. We do not have the proprietary restrictions that the USA has and should be able to break the ego barriers for price and excellent care now and the future.

I have lived in Sweden and the UK and I felt their systems were as good as Canada but they have problems as well.

UK has far superior treatment when it comes to mental health at least in Cambridge where I lived but it also varies greatly depending where you live. If you require emergency procedure or treatment no problem but if it is elective you really wait unless you go to the public side(private in Canada).

I worked for a large pharma company at the TA research head office and research physicians used to joke about how inefficient the USA system was but not the Canadian.

In Canada I have been volunteering at the board level of a successful hospice association in Ontario and have been frightening for increased funding. Though visiting hospices provide well trained volunteers to provide social and psychological support we receive no recognition from healthcare burocrates for the value we provide. Hospices in Ontario are forced to restrict services because of lack of funding. Beds in hospitals are plugged with people dying because of the lack of proper discharge notes and hand off to CCAC or long term care facilities.

I am a family medicine resident physician in Michigan planning to return to Ontario to practice.

There are a number of trends and observations I have made in the US so I will comment on a few.

1. Electronic Health Records and Healthcare Quality Benchmarks – These are the 2 biggest trends in primary care in the US. We are increasingly being told by private insurers in the US that for our patients with type 2 diabetes for example, how many of them have had an eye exam and foot exam in the past year, currently have blood pressures below 130 systolic, have LDL cholesterol levels below a certain level and have hemoglobin A1c levels below the benchmark. They actually pay the practice a certain number of dollars based on the overall % of benchmarks our practice has met as a whole and also tell us how much money has been “left on the table”. ie. additional money the practice could have earned had the benchmarks been met. It is a sort of “carrots and sticks” approach towards healthcare.

It can be extremely frustrating for doctors because it does not take into account patient noncompliance and lack of involvement in their healthcare and seems to put all the onus on the doctor. However it does force us as physicians to follow standards of care and educate our patients more often. The flip side is that patients who do not meet certain criteria like getting their cholesterol checked, continuing to smoke etc. pay higher co-pays, so for instead of a 10 dollar co-pay at each visit Mr Smith pays 25 dollars each time he visits the doctor. This might not be such a bad thing.

As for EHR there are very few doctors that sing its praises. There just is no uniform standard or system anywhere. Different practices use different systems and there is little interconnectivity. It often amounts to using a fancy word processor instead of paper charts and alot more typing and checkmarks for the doctor.

2. Lack of universal access to services in the US. I often make decisions based on the patient’s level of insurance coverage. For example, Mr Smith needs a screening colonoscopy due to his age and a family history of colon cancer. Mr Smith unfortunately has the “county health plan” and this does not cover screening. Only if he had active bleeding could we get him that colonoscopy. It can be very frustrating indeed. This is something that I brag about to my colleagues in the US that we fortunately do not have this problem in Canada.

3. Finally here in the US I can send my patient to the specialist and expect them to be seen within a reasonable amount of time (usually a few days or weeks). My main frustration comes from not always getting timely reports back from those specialists. I have heard that this has improved in Canada but I can see that not having a specialist’s opinion to back you up on occasion my prove to be frustrating from a professional standpoint.

It will be interesting to see how much of my experience in the US translates over to the Canadian system.

As someone who has observed and written about Canadian healthcare since the 1970s, I want to join Mary Szabo in her critique of this comparative commentary. The writers have organized their comments around their conception of what is important and thus waiting two months for a specialist is a problem. The report is about comparative statistics, not the experience of medical care in Canada as opposed to elsewhere. To do that would require deep knowledge of different systems, something the Commonwealth Foundation has not acquired. What is it like to deliver a child in various parts of Canada, how does that differ for a modest income person in Chicago or Toronto, two broadly similar cities, just as Vancouver and Seattle, or Minnesota and Manitoba are useful units of comparison. What happens if you have a heart attack in x or x setting? How about the treatment of cardio-vascular disease? How much paperwork does a patient with x hospitalization face? What about the thoracic surgeon who operated, or the internest whose patient it was. These are part of the comparative picture that is missing.

Thanks, Mr Marmor, for your comment. Had I been patient enough to read it, I might have cast a no vote on whether the report is fair to the Canadian system.

But I do think we’d be better off comparing Toronto to Paris, or Amsterdam, or Berlin or London rather than to cities In the US. We always compare ourselves to the big boy next door, but the US is such an outlier in so many areas of its domestic life, from gun deaths to poverty to infant mortality to wealth inequality, that I don’t think we get the information we need from these comparisons. Anyone can look good living next door to the Simpsons.

the only really compatibilities are the city sizes and the possible demographics. Except Maybe Chicago has a split SES (bimodal) rather than an smoother mean. Also depending on the sorts of “metrics” used for Quality of Care and access determinants(e.g. wait times) from who ever is doing the regulation that is going to be different too. So these systems are not really comparable on “outcome” by individual or group.
All sorts of confounding occurs.
The actual individual care provided at the “point of care” may very well be similar.
If there was an internist “hospitalist” that practise is less available in Canada that changes the continuity of care dynamic and therefore the resource use pattern (for the “better”?) in the tertiary care center in the USA .
What sort of patient navigation occurs during all this decision making? Is there a patient advocate assisting the one whose body it is that is being assaulted? Is there someone available to assist the person through the process during and after for them to feel as though they are still in charge of their heart, head and the remainder of their body and soul? Or are they being ‘resourced out’?
Given the information from the situation there are more differences and disparities than there are similarities.
All we really know is that :
specialists are trained similarly so operate similarly if the OR procedures are the same.
the cities are the similar size
the SES may be comparable (as a mean, but what are the modes and distribution of “insurance and access issues)
What are the teaching ctr. and care access similarities and differences?
There are specialists who are trained in very similar fashions due to tertiary care /teaching center models not effectively changing since WWII, especially for specialist
the payment and Quality metrics vary across both countries hence by institution/payee/ payer

Allocation of Beds is important, but allocation of the people working in the system is more important. Here in BC have shortages in many health care professions, from lab techs to respiratory therapists to occupational therapists. I would like to see some comparisons with European countries regarding number of various professions per capita, the shortages of doctors and their fees (which I suspect would be lower than in Canada ). I think these drive costs and wait times more than anything.

I’m a social worker in health care and I think the strongest feature of your report is the emphasis on the lack of residential care beds and lack of subacute care. I also wonder if other countries de-institutionalized their mentally ill population, as I think that’s an enormous hidden cost. Many hospital admissions could be avoided if people with mental illness got proper care in the community.

This report is so spun in favour of the private sector that it’s credibility should not just be disbelieved, but discounted. This is NOT my experience of the outstanding system we have in Canada. I guess it is necessary to attack what is good to protect what is crap… and that is what the American system is for the average American.

I have been in Canada for four years having lived in Scotland for the previous 55 years. This is a lovely country with lovely people but the healthcare system compares very poorly to the one I left. In Victoria, BC, I have waited between 4 and 7 months routinely to see a specialist. Appointments are then followed by anything between 2 and 8 months as you wait for tests (MRI wait was 8 months), then you have to wait to return to the specialist taking well over 6 months between referral and treatment is fast!). In one instance, I faced a 6 month wait for prolapse surgery on top of the 4 month wait to see the specialist, making 10 months in total. Time from GP referral to treatment is therefore routinely extensive. In Scotland the target is 18 weeks in total – I am not aware of similar targets in BC. In exasperation and discomfort, I have therefore had a hugely expensive operation through the rare private option in Vancouver (about to be challenged legally!) and returned to Scotland this year to see 2 private specialists at further additional cost. Not so great for a first world country – I remain dismayed. Dentists and vets are great – albeit immorally expensive – so my teeth and my dog are well catered for…. Access to low cost mortgages actually seems to be more important than access to good and timely healthcare. The one good thing I have encountered is the Walk In system. However if anything requires specialist referral or surgery, you’re back in appalling queues. Lovely country – your healthcare system needs overhauled.

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital.